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Bridging Market Approaches and Professionalism to Further Physician

Accountability and Improvement

American Board of Internal Medicine

The Blue Cross and Blue Shield Association

• The new role of professionalism in medicine and quality improvement

• 21st century Board Certification and its link to professionalism

• Certifying Boards’ interest in recognition/reward

• Blue Cross and Blue Shield plans’ interest in board certification

• How Blue Cross and Blue Shield plans are using certification as a marker of quality

Outline of Presentation

“Pay for performance is a third choice vehicle for crossing the quality chasm

among America’s purchasers. The first by a country mile is professionalism…but the speed of chasm crossing is too slow.”

Arnie Milstein,Medical Director, PBGH

Thought Leader, Mercer Consulting*

*Source: 2005 ABIM Foundation Forum Issue Brief

Push/Pull Forces on Performance ImprovementScience of Improvement• Build design support

capability• Practice analysis• Experience and

competency in QI and quality assessment

• Patient focus• Teamwork• Community resources

PUSHScience• Evidence-based practice• Errors and quality gap• Science of process and

outcome measurements

Professionalism• Culture of quality• Curious mind• Intolerant of quality gaps• Professional commitment

Increase number of health care systems measuring quality

Increase number of practitioners improving quality

Improved population healthBased on Orleans CT, Anderson N and Gruman J Roadmaps for the next frontier: Getting evidence-based behavior medicine into practice: Society of Behavioral Medicine, Annual Meeting, San Diego, March 1999

PULL• Payers & Government

– Rewarding performance

– Regulation• Patients/families/

advocacy groups• Market competition• Accreditation

– ACGME, LCME, NCQA, JCAHO

• Board Certification

Traditional Roles:• Professional competence and

responsibilities • Honesty• Patient confidentiality• Appropriate relations with patients• Scientific knowledge• Managing conflicts of interest

Professionalism—The Physician Charter

New Roles:• Commitment to improving quality of

care

• Commitment to improving access to care (principle of social justice)

• Commitment to a just distribution of finite resources

Professionalism—The Physician Charter

Quality Improvement TroikaOverarching goal: Alignment to reduce redundancy and accelerate improvement

The Role of Board Certification

Certifying BoardsIndependent, non-profit evaluation organization (not a membership society)70 years of rigorous standard-setting through high stakes examinationsWell-known marker of excellenceTrusted by the profession and the publicProven marker of higher quality care

Board Certification Matters

Surgery, 2002, Vol. 132, pp. 663-70

40% lower mortality rates for patients having colon resection

JGIM, 2006, Vol. 21(3), pp. 238-244

Higher rates of prescription of aspirin and beta blocker after AMI

JAMA, 2005, Vol. 294, pp. 473-81

Higher rates of preventive service (Mammography, hemoglobin A1c monitoring, influenza vaccination)

Acad. Med., 2000, Vol. 75, pp. 1193-98

15% lower mortality rate for patients with acute myocardial infarction (AMI)

JAMA, 2004, Vol. 292, pp.1038-43

Better outcomes and more reliable care

Board Certification correlates with…

• Adolescent Medicine• Cardiovascular Disease• Clinical Cardiac

Electrophysiology• Critical Care Medicine• Endocrinology, Diabetes

and Metabolism• Gastroenterology• Geriatric Medicine• Hematology• Infectious Disease• Interventional Cardiology• Medical Oncology• Nephrology• Pulmonary Disease• Rheumatology• Sleep Medicine• Sports Medicine• Transplant Hepatology

The Breadth of Internal Medicine

Certify 1 of every 3 physicians in US

Over 180,000 valid certificates

More internists than any other specialty

Most frequent patient encounter is with internist

ABIM’s Mission

To enhance the quality of health care

by certifying internists and

subspecialists who demonstrate the

knowledge, skills and attitudes

essential for excellent patient care.

Board Certification Today• Initial Certification• Periodic recertification (or “Maintenance of

Certification”) based on ACGME’s 6 competencies

• New emphasis on skills required to measure and improve performance (in the complex world of today’s health care)• Application of knowledge in patient care• Interpersonal and communication skills• Systems-based practice• Practice-based learning and improvement

Maintenance of CertificationRequired after 1989, recommended for all ABIM diplomatesCertificate valid for 10 yearsDiplomate must: • Hold an unrestricted medical license• Complete self-evaluation requirements

• Medical knowledge• Practice performance

• Pass a secure, cognitive examination

The Secure Examination• Cognitive simulation of practice• Predominantly assesses higher-order

intellectual abilities—not recallClinical judgment: >50%Synthesis: 20 to 35%Recall knowledge: <15%

• Includes conditions that could present to any practice, but doesn’t require knowledge that good practitioners should“look up”

Self -Evaluation of Medical Knowledge• ABIM self-evaluation products

– Recent advances and annual updates– Clinical Skills– Simulation – interventional cardiology– Quality improvement knowledge

• Society self-evaluation products– Credit granted if meet ABIM criteria– Currently ten society products

• Examples: MKSAP, ACC-SAP

Self-Evaluation of Practice Performance

• Designed to force “a new way of thinking”about quality and QI– Quality is not what the doctor does (but what

the system produces)– Quality improvement is not about working

harder (or learning more) but about diagnosing and treatment system problems”

• Designed to promote adult (experiential) learning by creating a safe and credible mechanism for self-evaluation

“If you want to teach people a new way of thinking, don’t bother trying to teach them, instead give them a tool, the use of which will lead to a new way of thinking.”

R. Buckminster Fuller

Self-Evaluation of Practice Performance

ABIM’s “Fullerene”

Performance Report

Improvement

Patient Data

Impact

PlanDo

StudyAct

Practice Systems

Practice Improvement Module (PIM)

• Asthma• Care of the Vulnerable Elderly• Clinical Prevention• Colonoscopy• Communication - Primary Care• Communication -

Subspecialists• Communication with Referring

Physicians

ABIM PIMs

• Diabetes (NCQA DPRP link)• Hepatitis C• HIV• Hospital-Based Care• Hypertension• Osteoporosis• Preventive Cardiology• Self-Directed

Available

In Development• Comprehensive Care

Certifying Boards’ Interest in Recognition and Rewards

• Reduce redundant data collection for physicians

• Increase the economic value of certification and recertification (Maintenance of Certification)

• Encourage more frequent and continuous participation in Recertification (Maintenance of Certification)

Interest by Certifying Boards (cont.) • Encourage “Grandfathers” to

participate in Maintenance of Certification

• Guidance for product evolution/ enhancement• Efficiency• Patient Safety• Focused Recognition

• Research opportunities

A Blue Cross and Blue Shield Association Presentation

The National Pay for Performance SummitBeverly Hills, CAFebruary 15, 2007

Bridging Market Approaches and Bridging Market Approaches and Professionalism to Further Physician Professionalism to Further Physician Accountability and ImprovementAccountability and Improvement

Office of Clinical AffairsOffice of Clinical Affairs

©© 2007 Blue Cross Blue Shield Association. All Rights Reserved.2007 Blue Cross Blue Shield Association. All Rights Reserved.

Office of Clinical Affairs

•• Creating relationships with physicians that reinforce consumer cCreating relationships with physicians that reinforce consumer confidence in the onfidence in the BluesBlues

•• Promoting publicPromoting public--private collaborations toward measurably improving overall private collaborations toward measurably improving overall quality and health outcomesquality and health outcomes

•• Supporting evidenceSupporting evidence--based decision makingbased decision making

BlueCross BlueShield Association BlueCross BlueShield Association


Parsimony Peers Professionalism

MotivationReward / RecognitionMeasurement

HEDIS

AHRQ

NCQA-recognized Programs

ABIM – MOC & PIMs

NQF & Quality Alliances

CMS

NCQA

BCBS Plans

Bridges to Excellence

Boards

Societies

Medicare Reporting P4P

Credentialing / Network Inclusion

$$$ Reward

Certification

CME Credit

Objective is to make life easier for physicians

Blue Plans and Board CertificationBlue Plans and Board Certification


•• Adoption of existing, industryAdoption of existing, industry--accepted performance measures accepted performance measures

•• Collaboration on measuring and improving overall physician perfoCollaboration on measuring and improving overall physician performancermance

•• Reimbursement systems and structures that align incentives for iReimbursement systems and structures that align incentives for improved overall quality mproved overall quality and outcomesand outcomes

•• Support knowledgeSupport knowledge--driven solutionsdriven solutions

•• Achieve better value, i.e., better aggregate health outcomes perAchieve better value, i.e., better aggregate health outcomes per dollar spentdollar spent

Collaboration with physicians is essential for transforming physician practices to improve overall quality and affordability



• Enables broader participation in Blue Plans’ programs where limited claims experience precludes valid measurement

• Enhances credibility and transformational potential through integration of clinical data

• Promotes transparency in recognizing clinical quality

Active participation in Maintenance of Certification complements Blue Plans’ measurement and reporting



Network Performance TransparencyNetwork Performance Transparency

Private and public sectors pushing for greater transparency on provider / practitioner performance

Private Public

Four Cornerstones of Four Cornerstones of ValueValue--Driven HealthcareDriven HealthcareRising Medical

Costs / Continued Cost-

Shifting

Growing Consumer-

Directed Market

Information on price and

quality

1. Connecting the System

2. Measure and Publish Quality

3. Measure and Publish Price

4. Create Positive Incentives


Blue DistinctionBlue Distinction

Blues’ innovative program to create an unprecedented level of transparency:

•• Goal 1: Engaging consumers to enable them to make more informed Goal 1: Engaging consumers to enable them to make more informed health care decisionshealth care decisions

•• Goal 2: Collaborating with providers to improve overall quality Goal 2: Collaborating with providers to improve overall quality outcomes and affordabilityoutcomes and affordability

•• Programs include:Programs include:

–– Blue Distinction National Transparency DemonstrationBlue Distinction National Transparency DemonstrationSMSM

–– Blue Distinction Centers for Specialty CareBlue Distinction Centers for Specialty CareSMSM

–– Blue Distinction Provider Measurement and Blue Distinction Provider Measurement and Improvement ProgramImprovement ProgramSMSM


National Transparency DemonstrationNational Transparency Demonstration

Blues engaged in a cohesive, dedicated effort to promote consumer engagement through transparency:•• Establish bestEstablish best--inin--class approach to quality, costclass approach to quality, cost--effective provider effective provider

selection selection

•• Launch comprehensive national wellness initiative to support heaLaunch comprehensive national wellness initiative to support healthier lthier behavior in the workplace and in the homebehavior in the workplace and in the home

•• Enhance national provider locator:Enhance national provider locator:

–– Information on price and qualityInformation on price and quality

–– ABIM Practice Improvement Module completionABIM Practice Improvement Module completion

–– NCQA Physician RecognitionNCQA Physician Recognition

–– Participation in Bridges to ExcellenceParticipation in Bridges to Excellence


Make criteria public

• Transplants

• Bariatric Surgery

• Cardiac Care

• Rare Cancer Care (2007)

Use aggregate clinical datanot individualized claims data

Centers for Specialty CareCenters for Specialty Care

Transparent quality criteria and clinical data are foundation


Provider Measurement and Provider Measurement and ImprovementImprovement

Initiatives designed to “raise the bar on quality” across Blue Plans’ networks

Hospitals Practitioners

Blues integrating selfBlues integrating self--assessment assessment and improvement programsand improvement programs

1. Medical Specialty Board Practice Modules

2. NCQA Physician Recognition

3. Bridges to Excellence

4. Patient-centered Medical Home

Blues initiating collaborations with Blues initiating collaborations with hospitals on:hospitals on:

1. Acute Myocardial Infarction

2. Heart Failure

3. Pneumonia

4. Surgical Infection Prevention

5. Patient Safety Indicators


Memorandum of Understanding

between BCBSA and ABIM, first of its kind between Board and

the health plan industry

Memorandum of Understanding

between BCBSA and ABIM, first of its kind between Board and

the health plan industry

Chris Cassel, MD addresses BCBSA Board of Directors

Chris Cassel, MD addresses BCBSA Board of Directors

Jun Jun 20052005

Mar Mar 20062006

Nov Nov 20052005

BCBS of NE first health plan to

launch collaboration with Board

BCBS of NE first health plan to

launch collaboration with Board

Horizon BCBS launches

collaboration with Board

Horizon BCBS launches


Independence BC launches


Independence BC launches


ABIM and The Blues’ collaboration began with historic agreement

ABIM and The Blues ABIM and The Blues

Highmark BCBS launches


Highmark BCBS launches



SelfSelf--Directed: Health Plan data Directed: Health Plan data acceptedaccepted

PIM:PIM:Medical Chart AuditMedical Chart Audit

Data Submitted Data Submitted to ABIMto ABIM

EXAMPLE: Independence BC provides practice performance data through Practice Quality practice performance data through Practice Quality Assessment Score (PQAS) and / or the ConnectionsAssessment Score (PQAS) and / or the ConnectionsSMSM Program SMARTProgram SMARTTMTM RegistryRegistry


Collaborations promote professionalism while minimizing burden of reporting on physicians


Reward

• Highmark BCBS

• QualityBlueSM quality-based incentive program

• PIM completion earns points for “Best Practice” QI initiative component of performance score

• Enhanced payment per patient

Blue Plans aligning incentives for practice transformation


Recognition

• BCBS of Nebraska

• Recognition of existing QI activities

• Award certificate for office display

• “Quality” designation in physician directory

• Reimbursement for annual PIM completion

Reward

• Horizon BCBS of NJ

• PIM completion an option to enhance quality component of performance score

• Top performance scores receive enhanced fee schedule


Launched

In Discussion

Emerging Interest

MT

MA

AK

HI

PR

ME

NHVT

RINY

PA NJOH

WVMD

VA

NC

SC

GA

FL

KSKY

TNAR

LA

MS AL

IA ILIN

MN WIMI

ND

SD

NEWY

CO

OKNM

TX

AZ

NVUTCA

MT

WA

ORID

DC

CTDE

Date: January 24, 2007


Momentum building among Blue PlansMomentum building among Blue Plans

MO


Expansion of collaborations planned for 2007:

•• Additional medical specialty boardsAdditional medical specialty boards

–– PediatricsPediatrics

–– Family MedicineFamily Medicine

–– UrologyUrology

–– OthersOthers

•• Additional Blue PlansAdditional Blue Plans



ContactsContacts

Allan M. Korn, MD FACPAllan M. Korn, MD FACPSenior Vice President & Senior Vice President & Chief Medical OfficerChief Medical Officer


312.297.6840312.297.6840

[email protected]@bcbsa.com

Nat Kongtahworn, MSNat Kongtahworn, MSManager, Network StrategiesManager, Network Strategies


312.297.6210312.297.6210

[email protected]@bcbsa.com

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